HospitalInspections.org

Based on observation, the hospital did not ensure that the patient had the right to personal privacy including privacy during treatment.

Finding includes:

1. On 5/25/11 at 11:35 a.m., a non-sample patient (Patient 32) who was in a wheelchair was observed in the public hallway outside of the nursing station. While in the middle of an interview with a physical therapy staff, a laboratory staff member approached the patient and told him that she needed a blood sample. Without waiting for acknowledgment or a response, the staff, interrupting the interview, proceeded to draw blood from Patient 32. When asked what the blood draw was for, the staff responded that it was for glucose testing.



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2. During observations of patient care in the ED (Emergency Department) on 5/26/11 at approximately 1:00 p.m., care was being provided to several non-sampled patients in an 'open' area across from the nursing station in the main ED. Specifically, the open area was previously labeled as "Exam 3" and "Exam 4" (as labeled on a copy of an ED unit floor plan obtained from the facility) where 20 chairs were assembled together in rows parallel and across from each other in a space approximately 15' x 25'.

Specifically, two non-sampled patients were observed receiving IV fluids and were sitting next to each other in adjacent chairs. Next to them approximately three (3) chairs over was a pediatric patient receiving an respiratory treatment. Across from these patients, a patient was being discharged to home and being given discharge instructions that included diagnosis, aftercare instructions, and other patient specific information.

Interviews were done with nursing staff at approximately 1:15 p.m. regarding the layout of the described area above. When asked about providing care or discharging patients from this area, LN 25 stated that she attempts to take patients to other areas of the ED for privacy when providing discharge instructions to patients to help protect patient confidentiality. She stated that "I try to take patients to Room A or B to help provide privacy when possible because everybody knows everybody on the island". LN 26 was also interviewed at approximately 1:20 p.m. regarding providing care and discharging patients from this area and said "there have been several complaints about privacy and all I can do is apologize to them (patients)."

Based on observation and interview, the hospital did not ensure that the patient had the right to receive care in a safe setting.

Findings include:

1. On 5/23/11 at 4:10 p.m., inspection of the emergency cart in the acute dialysis unit revealed the following:

a. Two of three laryngoscope blades in the emergency cart including one straight and one curve did not light up when connected to the laryngoscope handle.

b. A disposable kit labeled as a dual lumen catheter insertion tray (with laser-cut side slides) was observed on a table beside the same cart. The kit had an expiration date February 2009.

c. Two red-dot electrodes with an expiration date of March 2011 were also noted inside the cart.

2. During the same observation, several wands used to connect bicarbonate and acid solutions to the dialysis machines were observed partly submerged in a yellow plastic basin. While one end of the wands was submerged in disinfectant solution, the other end however was observed above the level of the solution rendering the wand inadequately disinfected.

In addition, a label on the basin indicated that the disinfectant used was a 10% "house bleach" solution. When asked what the hospital's policy and procedure was for the disinfection of reused dialysis items, a facility staff was unable to provide one but added that the wands should have been soaked in 1% house bleach as 10% was "strong" and was used only in the disinfection of dialysis machines used by patients with hepatitis B.


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3. On 5/23/11 at 9:45 a.m., during the initial hospital tour in the Labor and Delivery, three (3) open packages of Fetal Spinal Electrodes were observed inside the bedside drawer in Labor Room #1.

4. On 5/24/11 at 9:15 a.m. the following items were observed in the Adult Intensive Care Unit (ICU):

(a.) In one of the two crash carts, one Quick Arterial Blood Gas (ABG) 4062Z from Marquest had 100 units of Heparin had an expiration date of 06-2009.

(b.) The suction machine in one of the crash carts did not have a safety check label from Bio-Med.

(c.) An electronic programmer had a Biomed safety check sticker dated 8/3/10 and another sticker indicating an inspection due date of 3/31/11.

(d.) Multiple laryngoscopes were observed in the clean storage room. Four (4) straight blades (MAC 0, 1, 2, and 4) were non-functional. Three (3) curved intubation set (two MAC 4 and one MAC 3) were non-functional. Interview with the unit manager revealed that they need new batteries.

5. On 5/24/11 at 3:15 p.m., in Neonatal Intensive Care Unit (NICU) the following expired items were found in the crash cart:

(a.) One 10% Dextrose Injection 250 ml. - expiration date: 03-2011

(b.) One ET size 3.0 - expiration date: 02-2010

(c.) Three ET size 2.5 with holder 2.5 - expiration date: 02-2010

(d.) One Pedi-cap CO2 detector for 1 kg. - 15 kg. Pediatric - expiration date: 06-2009

6. On 5/25/11 at 4 p.m., in Telemetry unit, an endotracheal tube (ET) size 7.0 with an expiration date of 08-2010 was observed inside of one of the unit's crash carts.


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7. Based on record review and interview the facility staff failed to provide cardiac catheterization in a safe setting for 1 of 5 residents seen on 5/24/11. The radiology staff did not take steps to prevent a door from closing thus causing equipment used for cardiac catheterization to overheat and shut down while a patient was on the procedure table. The equipment failure could have been delayed medical care or could have created serious complications if the patient needed emergency assistance during the equipment failure. The findings include:

On 5/24/11 Patient 5 was admitted for a same day procedure to perform cardiac catheterization. The procedure called for a sheath to be placed in the right femoral artery and advanced through the artery using a guide wire. The sheath was placed in blood vessels in the heart to improve circulation . The physician used radiological equipment (a fluoroscope) to visualize the anatomy as the sheath was advanced through the blood vessels to the heart. The medical record showed that the patient arrived at the procedure room at 10:55 a.m. and case ended at 12:20 p.m.

On 5/25/11 at 9 a.m. the physician who performed the procedure on Patient 5 was interviewed. He stated the patient was on the table but the catheter had not been advanced into the blood vessel when the equipment failure occurred. In addition, the director of the radiology department stated that his staff knew that the door outside of the procedure room had to be open to prevent equipment overheating. This had happened before. His staff had propped the door open but an employee from outside of radiology had removed the door prop. There radiology staff did not notice that the door had closed until the equipment overheated. The door was reopened, fans were directed at the equipment and the equipment was restarted.

8. Based on observation and interview the facility staff failed to date multidose vials of medication sand date IV tubing for 1 patient.

On 5/23/11 at 3:10p.m. RN 21 took an undated open 30 ml bottle of bacteriostatic 9 % Normal Saline solution and drew up 5 ml into a syringe. The nurse used the syringe to flush the peripheral IV port in the left hand of patient #3 . The nurse stated that the bottle should have been dated when opened but she was sure it was fine because it was almost full. There were empty IV minibags and tubing hanging on the IV pole at the patient ' s bedside. The patients daughter stated that they had been used to give IV medication to her mother earlier in the day. There was no date on the IV tubing. The nurse stated that the tubing should have been dated and changed every 72 hours and without a date it would be impossible to accurately determine the correct time to change the tubing


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9. During a tour of the ED (Emergency Department) Annex on 5/23/11 at approximately 11:00 a.m. located across the corridor from the main ED, the Crash Cart was inspected. The Daily Crash Cart Checklist (A checklist whereby nursing staff inspect the crash to ensure that all emergency equipment is located on/in the cart and operational) had not been checked by staff for the previous four (4) days.

During an interview with the LN 27 on 5/26/11 at approximately 12:45 p.m., she stated that the crash cart in the ED Annex was to be checked daily on "every shift by the Charge Nurse or nursing staff on-duty." Further, she stated that "sometimes we don't check it when we don't have patients here, but should be checked regularly."

Review of the facilities Policy titled "Checking of Emergency Equipment and Supplies (Crash Cart)" stated that "this mechanism assures emergency equipment and supplies at the beginning of each shift in all nursing units to ensure the availability and proper functioning of supplies and equipment during an emergency..."

Based on observation and interview, the hospital did not ensure the confidentiality of patients' clinical records.

Findings include:

1. Based on observations in the trauma side of the ED on 5/26/11 at 1:00 p.m., a stationary desk was located in the ED across from patient care gurneys and a walkway used by staff and patient family/visitors. Located on the desk, in a viewing angle towards patients and families/visitors, was a computer monitor displaying patient information including name, diagnosis, treatment orders, nursing notes, and other data related to patients being held in the ED. Being that the hospital utilizes an Electronic Health Record (EHR) system, nursing staff would regularly type in various aspects of patient information into the computer terminal that would display on the screen. During this particular observation, a nurse had entered patient data into the terminal (displayed on the monitor), and then left the terminal (and desk) to go do something in another area of the ED. On the screen was the name, diagnosis, and treatment orders regarding a patient being treated in the ED. The information contained on the screen was in full view of patient families/visitors who were standing at the sides of patient gurneys, or otherwise walking through the area near the vicinity of the desk and monitor.

During an interview with the LN 27 on 5/26/11 at approximately 2:23 p.m., she stated that there "used to be a computer screen cover that was over the monitor screen that shielded view of the information on the screen." She stated that the device had been damaged, and that she has unsuccessfully "been trying to get a replacement screen privacy shield, but have not yet received one" from the applicable department. "I know we should have something there to cover that information."

Based on observation, interviews, and record review, the facility failed to show evidence that physical restraints were used only when less restrictive interventions were determined to be ineffective to protect the patients from harm for two of 30 sample patients.

Findings include:

1. On 05/25/11 at 2:45 p.m., 05/26/11 at 9:15 a.m. and 05/27/11 at 9:30 a.m., non sample Patient 35 was observed lying calmly in bed and with soft restraints applied to both wrists and tied to the mattress frame. In an interview, the licensed nurse stated that the patient was restless and agitated at times and had attempted to pull the ET.

Review of the patient's medical record revealed the patient was admitted in adult ICU on 5/17/11 with a diagnosis of respiratory failure. The physician's Report of Consultation dated 05/17/11 indicated that the patient had a history of chronic obstructive pulmonary disease (COPD) and emphysema. The patient was intubated due to hypoxia and chest x-ray showed congestive heart failure (CHF), COPD and right lower lobe pneumonia.

Review of physician's "Medical-Surgical Restraint Order" dated 5/18/11 at 8:30a.m. showed an order for soft restraints to be applied on both wrists for 24 hours with "sedation" checked off as justification for restraint. The alternative interventions attempted include relocation closer to nursing station and patient reorientation.

Review of six (6) Behavioral/Activity Assessment forms dated 05/18/11 in the i-Med computer system confirmed that bilateral soft wrist restraints were applied on non-sampled Patient 35. The patient's level of consciousness was documented as "sedated" and behavior was "calm." The "release criteria (based on physician order form) were documented as "not met. "

The physician order form indicated the criteria for release intervention (check all that apply) as follows: patient is cooperative/coherent; patient is calm; patient is oriented.

On 05/19/11 the physician's order for wrist restraints was renewed for 24 hours due to pulling on lines or tubes and "sedation " Review of six (6) behavioral/activity assessment forms showed evidence that the patient's behavior was calm and the level of consciousness was sedated, however, the criteria for physical restraint release was not met.

On 05/20/11, the physician's order was again renewed for 24 hours due to pulling on lines or tubes. Two (2) of the five (5) Behavior/Activity Assessment forms revealed the patient's behavior as "calm, anxious/agitated" at 4:49 p.m. and 4:53 p.m.

Documentation for 5/21/11 to 05/23/11 indicated the patient was calm and sedated. From 5/24/11 to 5/27/11, the patient's behavior showed that whether he was awake or sedated, he was cooperative. However, there was no evidence that changes occurred with the restraint use order nor the physical restraint release criteria were met.

The physician's order revealed that the application of wrist restraints was renewed daily from 05/18/11 to 05/27/11. Although the physician's orders included alternative interventions checked off in the list, there was no evidence in the record when the alternative measures were attempted and the results of attempts whether effective or ineffective to reduce the application of physical restraints.

2. On 5/26/11 at 9:20 a.m. and on 5/27/11 at 9:30 a.m., non sample Patient 36 was observed in bed calm and resting in bed. Soft wrist restraints were applied to both hands fastened to the mattress frame of the bed. Review of the patient's medical record revealed the patient was admitted to the facility on 5/15/11 with diagnoses of sepsis, left lower lobe pneumonia, and diabetes mellitus.

On 5/26/11 at 9:40 a.m., the licensed nurse stated that soft wrist restraints were needed because the patient attempts to pull at the ET when restraints were released. At 9:45 a.m., upon surveyor request, the licensed nurse showed the Behavioral/Activity Assessment form in the iMED computer system as she completed the restraint use assessment. The documentation revealed the patient was awake, anxious/agitated. Also the patient's behavior for continued restraint restraint use showed, "Pt (patient) attempting to pull at ETT when restraints released."

A review of all the Behavioral/Activity Assessments dated 5/21/11 to 5/25/11 including 5/26/11 at 6:24 a.m. prior to 9:40 a.m. documentation revealed no evidence in the medical record that an assessment of specific patient behavior was conducted to justify the continued restraint use for medical-surgical reasons. The patient's level of consciousness varied from sedated, asleep or awake and patient's behavior was calm behavior.

The physician's orders that included all the less restrictive alternatives checked off, however, there was no documentation as to when they were attempted and whether any of the alternatives was effective for nonsample Patient 36.

Based on observation, interviews and record review, the facility did not ensure that the use of restraint was in accordance to the patients' plan of care.

Findings include:

1. Patient 7 was admitted to the facility on 05/11/11 in the medical floor with diagnoses of right lower lobe lung mass associated with hemoptysis. The patient was admitted to the adult ICU on 05/16/11, intubated and connected to a mechanical ventilator.

Review of the Nurse's Notes revealed that on 05/16/11 at 10:25 a.m.-11:25 a.m., the patient agreed to be intubated for 5 days. After the intubation was completed, the patient was restless and 2 milligrams (mg) of Versed was given twice, however, the patient continued to be agitated, bucking the ventilator. Vecoronium 10 mg was given intravenously, after which the patient calmed down.

The medical record also showed that on 05/16/11, at 11:00 a.m., the physician ordered soft restraints to be applied on the patient's right and left wrists for 24 hours. The Medical-Surgical Restraint Order form indicated the following behaviors as justification for the restraint order: "pulling on lines or tubes; forgetful, impulsive, limited safety awareness; fall potential; and sedation."

On 05/26/11 at 9:00 a.m., the unit manager stated that the physical restraint ordered for Patient 7 was never applied because the patient's agitation post intubation was controlled by sedation. The unit manager also confirmed that after the physician's order was written, there was no documentation in the medical record that the physical restraint order was not carried out because sedation was effective in addressing Patient 7's behavioral problem of pulling out the ETT (endotracheal tube).

There was no plan of care formulated to address patient's behavior of agitation and restlessness that sedation was an effective behavior management rather than the use of physical restraints.

2. On 05/25/11 at 2:45 p.m., 05/26/11 at 9:15 a.m. and 05/27/11 at 9:30 a.m., non sample Patient 35 was observed lying calmly in bed and with soft restraints applied to both wrists and tied to the mattress frame. In an interview, the licensed nurse stated that the patient was restless and agitated at times and had attempted to pull the ET. Review of the patient's medical record revealed the patient was admitted in adult ICU on 5/17/11 with a diagnosis of respiratory failure.

Review of physician's "Medical-Surgical Restraint Order" dated 5/18/11 at 0830 showed an order for soft restraints to be applied on both wrists for 24 hours with "sedation " checked off as justification for restraint.

The physician order form indicated the criteria for release intervention (check all that apply) as follows: patient is cooperative/coherent; patient is calm; patient is oriented.

Behavioral assessment from 5/21/11 to 05/23/11 indicated the patient was calm and sedated. From 5/24/11 to 5/27/11, the patient's behavior showed that whether he was awake or sedated, the patient was cooperative. However, there was no evidence that changes occurred with the restraint use order nor the physical restraint release criteria were met.

The physician's order revealed that the application of wrist restraints was renewed daily from 05/18/11 to 05/27/11.

There was no plan of care for Patient 3's use of physical restraints and the need to modify the restraint use in accordance to patient's behavioral assessments as indicated in the facility's policy and procedures.

3. On 5/26/11 at 9:20 a.m. and on 5/27/11 at 9:30 a.m., non sample Patient 36 was observed in bed calm and resting in bed. Soft wrist restraints were applied to both hands fastened to the mattress frame of the bed. Review of the patient's medical record revealed the patient was admitted to the facility on 5/15/11 with diagnoses of sepsis, left lower lobe pneumonia, and diabetes mellitus.

On 5/26/11 at 9:40 a.m., the licensed nurse stated that soft wrist restraints were needed because the patient attempts to pull at the ET when restraints were released. At 9:45 a.m., upon surveyor request, the licensed nurse showed the Behavioral/Activity Assessment form in the iMED computer system as she completed the restraint use assessment. The documentation revealed the patient was awake, anxious/agitated. Also the patient's behavior for continued restraint restraint use showed, "Pt (patient) attempting to pull at ETT when restraints released."

A review of all the Behavioral/Activity Assessments dated 5/21/11 to 5/25/11 including 5/26/11 at 6:24 a.m. prior to 9:40 a.m. documentation revealed no evidence in the medical record that an assessment of specific patient behavior was conducted to justify the continued restraint use for medical-surgical reasons. The patient's level of consciousness varied from sedated, asleep or awake and patient's behavior was calm behavior.

Further review of the medical record showed no evidence that a plan of care was formulated to address the use of physical restraints and how the plan was modified as the behavior of the patient changed.


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4. On 5/24/11 the Patient 2 was transferred to the medical surgical unit of the hospital. The medical record showed that the patient had been placed in 2 soft wrist restraints on 5/19, 5/20, 5/21, and 5/24/11. There was no care plan for the use of restraints. The record had an unsigned assessment of the resident with a date. It was a check off sheet but it did not indicate who had made the assessment.

On 5/25/11 at 11 a.m. the nurse manager for the unit, RN 20, was interviewed and she agreed that the assessments were unsigned and not timed. She stated that it was hospital policy for staff to sign, time and date entries in the medical record. She could not locate an individualized care plan for restraints for this resident.

Based on record review and interview the physician did not sign the medical-surgical restraint order for Patient 2 on 4 occasions. The use of restraints without an order is a violation the residents rights and is a danger to the health and safety of the resident. The findings include:

On 5/24/11 Patient 2 was transferred to the medical surgical unit of the hospital. The medical record showed that the patient had been placed in 2 soft wrist restraints on 5/19, 5/20, 5/21, and 5/24/11 without a medical order. The forms had as assessment of the resident checked off but it did not indicate which staff had made the assessment.

On 5/25/11 at 11 a.m. the nurse manager for the unit, RN 20, was interviewed and she agreed that the orders were unsigned and stated that it was hospital policy for the physician to sign the order for soft wrist restraints every 24 hours.

Based on observation, interviews and record review, the facility did not ensure that restraints were discontinued at the earliest possible time, regardless of the length of time identified in the order.

Findings include:

1. On 05/25/11 at 2:45 p.m., 05/26/11 at 9:15 a.m. and 05/27/11 at 9:30 a.m., non sample Patient 35 was observed lying calmly in bed and with soft restraints applied to both wrists and tied to the mattress frame. In an interview, the licensed nurse stated that the patient was restless and agitated at times and had attempted to pull the ETT.

Review of the patient's medical record revealed the patient was admitted in adult ICU on 5/17/11 with a diagnosis of respiratory failure. The physician's Report of Consultation dated 05/17/11 indicated that the patient had a history of chronic obstructive pulmonary disease (COPD) and emphysema. The patient was intubated due to hypoxia and chest x-ray showed congestive heart failure (CHF), COPD and right lower lobe pneumonia.

Review of physician's "Medical-Surgical Restraint Order" dated 5/18/11 at 8:30a.m. showed an order for soft restraints to be applied on both wrists for 24 hours with "sedation" checked off as justification for restraint.

Review of six (6) Behavioral/Activity Assessment forms dated 05/18/11 in the i-Med computer system confirmed that bilateral soft wrist restraints were applied on non sample Patient 35. The patient's level of consciousness was documented as "sedated" and behavior was "calm." The "release criteria (based on physician order form) were documented as "not met."

The physician order form indicated the criteria for release intervention (check all that apply) as follows: patient is cooperative/coherent; patient is calm; patient is oriented.

On 05/19/11 the physician's order for wrist restraints was renewed for 24 hours due to pulling on lines or tubes and "sedation " Review of six (6) behavioral/activity assessment forms showed evidence that the patient's behavior was calm and the level of consciousness was sedated, however, the criteria for physical restraint release was determined not met.

On 05/20/11, the physician's order was again renewed for 24 hours due to pulling on lines or tubes. Two (2) of the five (5) Behavior/Activity Assessment forms revealed the patient's behavior as "calm, anxious/agitated" at 4:49p.m. and 4:53p.m.

Documentation for 5/21/11 to 05/23/11 indicated the patient was calm and sedated. From 5/24/11 to 5/27/11, the patient's behavior showed that whether he was awake or sedated, he was cooperative. However, there was no evidence that changes occurred with the restraint use order nor the physical restraint release criteria were met.

The physician's order revealed that the application of wrist restraints was renewed daily from 05/18/11 to 05/27/11. There were no aggressive measures taken to show the effectiveness of the alternative interventions checked off in the lists to reduce the application of physical restraints.

2. On 5/26/11 at 9:20 a.m. and on 5/27/11 at 9:30 a.m., non sample Patient 36 was observed in bed calm and resting in bed. Soft wrist restraints were applied to both hands fastened to the mattress frame of the bed. Review of the patient's medical record revealed the patient was admitted to the facility on 5/15/11 with diagnoses of sepsis, left lower lobe pneumonia, and diabetes mellitus.

On 5/26/11 at 9:40 a.m., the licensed nurse stated that soft wrist restraints were needed because the patient attempts to pull at the ET when restraints were released. At 9:45 a.m., upon surveyor request, the licensed nurse showed the Behavioral/Activity Assessment form in the iMED computer system as she completed the restraint use assessment. The documentation revealed the patient was awake, anxious/agitated. Also the patient's behavior for continued restraint restraint use showed, "Pt (patient) attempting to pull at ETT when restraints released."

A review of all the Behavioral/Activity Assessments dated 5/21/11 to 5/25/11 including 5/26/11 at 06:24 a.m. prior to 9:40 a.m. documentation revealed no evidence in the medical record that an assessment of specific patient behavior was conducted to justify the continued restraint use for medical-surgical reasons. The patient's level of consciousness varied from sedated, asleep or awake and patient's behavior was calm behavior.

The physician's orders showed that all the less restrictive alternatives listed were checked off, however, there was no documentation of the results of attempts done to reduce the use of restraints or to justify the continued use of soft limb restraints for non sample Patient 36.

Review of the facility' s policy and procedure on restraint use (Policy Number: 630-II-C-30) revealed that documentation of restraints use and assessment is to be done in the iMED.

Justification of restraint use (for each restraint episode) shall be documented in the Restraint Use Justification Assessment. Ongoing restraint assessments shall be documented in the Behavior, Activity Assessment. On staff education, they should be trained in choosing the least restrictive intervention based on an individualized assessment of patient's medical or behavioral status or condition.

Based on document review and interview, the hospital did not always examine the credentials of members for reappointment to the medical staff.

Finding includes:

Review on 5/27/11 of the credential file for the current privileging period ending 6/01/11 revealed an evaluation checklist completed by Dr. 26 attesting that he had not had any hospital privileges suspended. Further review of the credential file however revealed that on 5/25/08, Dr. 26's hospital privileges were suspended and then reinstated on 5/26/08.

Review of the medical staff by-laws (revised 2/01/10) concerning applications for staff appointment noted that processing of the application can either be through the "Standard Process" or by the "Alternative Process." The bylaws further noted that an application cannot be processed via the "Standard Process" if the "applicant has received involuntary limitation, reduction, denial or loss of clinical privileges." This notwithstanding, the credential file lack documented evidence that the Alternative Process review was conducted, that the file including the evaluation completed by Dr. 26 was reviewed by the credentials committee for accuracy, and that subsequent reapproval for medical staff membership took into consideration the information noted on the evaluation.

During the survey, review of radiology reports revealed that Dr. 26 had over a hundred that had no interpretation or were either unsigned or not signed timely rendering the reports preliminary instead of final. On 5/25/11 at 11 a.m., the director of medical records provided two lists of incomplete radiology records. The first list of 128 patients was titled "Orders Without Results;" and the director stated that this represented radiologic procedures for which there were no interpretation or radiologist's signature. The second list was titled "Orders with Preliminary Results" and the director stated that this represented radiological procedures which had not had a final reading and were not signed by the radiologist.

On 5/25/11 at 11:30 a.m., the director of the radiology department was asked about the status of the 232 radiology reports. He stated that he and other staff were aware of the problem. The director added that there was a departmental plan being developed to address the issue but that it had not been enacted.

Review of the medical staff bylaws (revised 2/10/11) pertaining to reports of procedures, tests, and results required that "Reports of pathology and clinical laboratory examinations, radiology, and nuclear medicine examinations or treatments, anesthesia records, and other diagnostic or therapeutic procedures shall be completed promptly, authenticated, and filed in the record, within twenty-four (24) hours of completion, if possible."

Interviews with hospital staff revealed that getting the reports signed promptly by Dr. 26 was an ongoing issue. During an interview on 5/27/11, a member of the medical staff confirmed that Dr. 26 had been informed about the need to ensure that radiology reports were promptly completed and signed. (Cross-refer to V554.)

Based on interview and record review the facility failed to ensure that a history and physical exam was completed and documented within 24 hours after the hospital admission for 1 of 30 sampled patients. Failure to have a written history and physical examination in the medical record could negatively impact the patient's course of treatment and put the patient at risk for additional problems while in the facility.

Findings include:

Sample patient number 29 is an 80 year old female admitted into the facility on May 22, 2011. Some of her diagnoses included: Respiratory Failure and Cachexia. The medical record was review with LN3 on May 26, 2011 at 9:15a.m. LN3 acknowledged the patient was admitted on May 22, 2011 and that the medical record did not contain a written history & physical exam (H&P). During a concurrent interview LN3 stated the H&P exam should have been placed in the chart 24 hours after admission and she validated the absence of a hand written H&P or brief admission note within the medical record.

On May 26, 2011 the GMHA Medical Staff Bylaws dated 2/01/2010 were reviewed. On page 4 of the Bylaws under the section addressing the H& P the guidance indicates the "H&P must be recorded within 24 hours of admission and present on the chart ..."

Based on observation, interview, and record review, the hospital did not ensure that the registered nurse supervised and evaluated the nursing care for each patient.

Findings include:

1. Patient 24 was admitted to the hospital on 5/20/11 with several diagnoses including end-stage renal disease with dialysis, debridement of a sacral pressure sore, and anemia. Nurses notes dated 5/20/11 described Patient 24 as alert, oriented to person, but "unable to verbalize thoroughly." General admission notes dated 5/20/11 further described the patient as dependent on staff for all activities of daily living (ADLs).

Review of the medical record revealed that Patient 24 was admitted with pressures sores on the sacral area and on the left hip. Nurses notes dated 5/20/11 described the pressure sores as being a "Stage 3" (full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the ulcer presents clinically as a deep crater with or without undermining adjacent tissue). On 5/27/11, the wound assessment noted that Patient 24's pressure ulcers were described as Stage 4 (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures such as tendon or joint capsule) and that the left hip ulcer measured 5.6 cms X 6 cms X 2 cms; and the sacral ulcer, 9.5 cms X 8 cms X 3 cms in size.

The hospital's pain management policy (revised 1/2008) noted that all patients "have the right to effective management of their pain" which "includes appropriate screening and assessment for pain, care and treatment of their acute and/or chronic pain, and education as to how to manage their pain on an ongoing basis, as well as attention to any needs related to their continuum of care." The policy also noted that "pain scale tools will be utilized" including the Wong-Baker FACES for pediatric patients ages 3 - 10 or for non-English speaking population; as well as the Visual Analog Scale consisting of a 0 - 10 rating for patients >10 years of age.

Review of the medical record revealed a pain level flowsheet noting that Patient 24 had "mild pain" on two of 19 days (5/23/11 and 5/25/11) of pain assessments; and having "no pain" for 17 days of the assessments. Further review of the medical record however revealed the lack of documentation of the pain scale tool used for Patient 24 to ensure that the assessment was accurate and appropriate in light of her cognitive status. The same policy noted that for patients "who are unable to verbalize their pain, wherein the behavioral pain tools will be utilized, documentation shall include which pain scale tool was used, along with observable behaviors (facial expressions, body movement, crying) and physiological measures (vital signs).

Review of the pain level flowsheet also revealed that assessments were not consistent with the policy that "pain reassessment shall occur every four hours on all patients, as the fifth vital sign." On 5/23/11, 5/24/11, 5/25/11, and 5/26/11, for example, the flowsheets did not indicate that assessments were conducted every four hours as required. On 5/25/11, for instance, pain assessment was conducted only once.

At 10:15 a.m. on 5/25/11, Patient 24 was observed in the acute dialysis unit moaning during treatment. When asked if the patient was in pain or uncomfortable, a licensed staff stated that Patient 24 was "always doing that," and that she was "confused." Review of the medical record revealed the lack of indication that an assessment to determine the reason for the behavior was conducted.

During observation of wound care dressing on 2:25 p.m. on 5/25/11, Patient 24 was moaning and repeatedly stating, "It hurts... It hurts...it hurts..." during the procedure. The licensed staff changing the dressing stated that the patient "was more awake today," and added that "it's good because she's talking." Review of the medical record revealed that while the patient was noted as having "mild pain" at 12:00 p.m. (on 5/25/11), there was no consideration or reassessment to determine if the patient might require pain medication prior to the dressing change.

Record review also indicated that in spite of the extensive pressure sores, Resident 24 did not have any physician's orders for pain relief. While a physician's order for the use of Tylenol 325 mgs 2 tabs every 4 hours as necessary was written on 5/24/11, this order was not specific for pain control. In addition, there was no evidence that a care plan for pain as a problem for Patient 24 was developed.

2. Patient 23 was admitted to the hospital on 5/12/11 with several diagnoses including uncontrolled diabetes and leg cellulitis. The general admission notes dated 5/12/11 described Patient 23 as having no problems with his neurological and mental status and that he was independent in all activities of daily living. The same notes also revealed that the patient had pain on his right lower extremity at a level of "8."

Review of the medical record revealed that Patient 23 had physician's orders dated 5/12/11 for the use of Percocet 2 tabs every 4 hours for pain. Medication administration records (MAR) however revealed that the order was not always followed and that Patient 23 was given two tabs of Tylenol 325 mgs for pain including on 5/13/11 at 1:00 a.m. and 11:50 a.m.; on 5/14/11 at 12:40 a.m. and 8:20 a.m.; on 5/17/11 at 8:45 p.m.; on 5/22/11 at 7:30 p.m.; on 5/23/11 at 8:20 a.m., and on 5/24/11 at 2:00 a.m.. Further review of the record revealed that the physician's order for the Tylenol dated 5/12/11 was for the administration of two 325-mg tabs every 4 hours as necessary "for fever."

Review of the pain assessment sheet including on 5/14/11, 5/15/11, 5/18/11, and 5/19/11 also indicated that Patient 23 had complained of pain and while medications were given, the effect of each administration was not always documented to determine if an acceptable level of pain relief was attained. The care plan dated 5/12/11 noted that after administration of pain medications, staff had to document effectiveness.

Further review of the medical record revealed the lack of documentation of the pain scale used in assessing Patient 23's level of discomfort. While staff noted the numerical value of pain on the assessment sheet, there was no indication if the number was Patient 23's or the licensed staff's perception of the patient's discomfort. Review of nurses notes revealed the lack of written indication that Patient 23 was instructed and understood the use of the pain scale tool to ensure that the numbers noted reflected Patient 23's discomfort.

During an interview on 5/25/11 following wound care observation at 11:00 a.m., Patient 23 stated that licensed staff had different ways of assessing his pain. The patient explained that some licensed staff members would inquire if he had pain and that others would ask for a specific number for the pain. He added that at times, staff would ask if he wanted 1 or 2 tablets.

Further review of Patient 23's medical record revealed laboratory tests results obtained on 5/12/11 which noted a low albumin level of 2.7 (normal limits 3.4 - 5.0). While the medical record indicated that Patient 23 was seen by a dietary technician and documentation of the encounter on 5/23/11 included blood sugar level and hemoglobin and hematocrit findings, diarrhea, food consumption, and increasing fluid intake, there was no indication that the low albumin level was identified or addressed particularly to support healing of the wounds on his right leg. In addition, there was no documentation that the attending physician was informed. During an interview on 5/26/11, a nursing supervisor staff stated that laboratory results outside of normal limits should have been noted by nursing staff and conveyed to the attending physician.

3. Patient 22 was admitted to the hospital on 5/22/11 with several diagnoses including diabetes, hypertension, and cellulitis of the right hand. General admission notes dated 5/22/11 described Patient 22 as having no neurological and mental status abnormalities, that she was independent in all activities of daily living, and that her preferred language for discussion of health needs/management was Chuukese. The admission notes also indicated that she had pain on her right hand which was described at an intensity of "5."

In an interview on 5/25/11 at 4:15 p.m., Patient 22 indicated that she continued to have pain on her right hand but that it was tolerable at the moment and that she maintained her right arm elevated on a pillow. Patient 22 also stated that her English was limited. During the conversation, several handouts were observed on her nightstand which she explained were given to her by hospital staff. When asked if she had read the handout including that on "Pain Management," Patient 22 stated that her primary language was Chuukese and that she could not read nor understand what was written. A licensed staff assigned to the patient who was interviewed on 5/25/11 stated that Patient 22 was "illiterate."

Review of the care plan dated 5/22/11 on alteration in comfort revealed that while interventions outlined included assessing and documenting pain characteristics such as quality, location, radiation, duration and precipitating factors, there was no documentation of any pain scale tool used in consideration of the language barrier to ensure that the assessment was accurate and reflected what Patient 22 experienced. Though the pain level sheet noted "0" for no pain, and "1" for mild pain, there was no indication if the numerical values were those of the patient's. Further review of the pain assessment sheet revealed that while Patient 22 was given pain medications including on 5/23/11, 5/24/11, and 5/25/11, the effects of the administration of the analgesics were not always documented.

Further review of Patient 22's medical record revealed that laboratory test results dated 5/23/11 included a low albumin level of 2.1 (normal limits 3.4 - 5.0). This notwithstanding, there was no indication in the record that the physician or registered dietitian was informed or that a referral was made for dietary screening as outlined in the Nursing Nutrition Screen algorithm. Review of the record also revealed the lack of evidence that a care plan was developed to address the patient's low albumin level which is important in facilitating wound healing.



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4. On 5/25/11 at 2 p.m. Non Sampled Patient 2 was admitted to medical surgical floor prior to a scheduled gall bladder surgery. The resident had an order for 75 to 100 mg of Demerol (a narcotic pain medication) IM (intra muscular injection) every 3 to 4 hours as needed for pain. The nurse reviewed the order but did not clarify the order.
At 3:35p.m the nurse drew up 75 mg of Demerol and went to the patient's room.

At 3:40 p.m. the nurse entered the room and asked the patient about his pain. He stated his pain was 10 out of 10 ( the most severe) and the patient's friend asked if that was 100 mg and stated, " the last time they gave him 75 and it didn ' t hold him very long. " The nurse stated that it was 75mg and asked the patient if he wanted the medication or not. The patient stated, " let's try it." The nurse gave the medication.

Based on observation, interview and record review the facility failed to ensure that the nursing staff develops and keeps current, a nursing care plan for 4 of 30 sampled patients. Failure to have a current nursing care plan in the medical record can impact patient's quality of care while in the hospital and after discharged from the hospital.

Findings include:

1. Sample patient number 29 is an 80 year old female who lives with her husband and was admitted into the facility on May 22, 2011. Some of her diagnoses included: Respiratory Failure and Cachexia. The medical record was review with LN3 on May 26, 2011 at 09:15AM; four days after admission. The LN3 acknowledged the patient the medical record did not contain a written discharge nursing care plan. Additional record review revealed the initial nursing assessment identified there was no indication to refer to any other department to address the patient's real or potential discharge home care needs (such as equipment, home health agency referral or skilled nursing facility placement). The medical record did not reflect written documentation or a nursing care plan alluding to a tentative referral to the Social Services Department, post discharge home needs or consideration of Home Health Agency/Skilled Nursing Facility placement.


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2. Patient 24 was admitted to the hospital on 5/20/11 with several diagnoses including end-stage renal disease with dialysis, debridement of a sacral pressure sore, and anemia. Nurses notes dated 5/20/11 described Patient 24 as alert, oriented to person, but "unable to verbalize thoroughly." General admission notes dated 5/20/11 further described the patient as dependent on staff for all activities of daily living (ADLs).

Review of the medical record revealed that Patient 24 was admitted with pressures sores on the sacral area and on the left hip. On 5/27/11, the wound assessment noted that Patient 24's pressure ulcers were described as Stage 4 (full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures such as tendon or joint capsule), and that the left hip ulcer measured 5.6 cms X 6 cms X 2 cms; and the sacral ulcer, 9.5 cms X 8 cms X 3 cms in size.

Review of the medical record revealed that despite the pressure sores, Patient 24's drug regimen did not include any medication for pain control. While a physician's order dated 5/24/11 noted the use of two Tylenol 325-mg tabs every 4 - 6 hours as necessary, the order did not specify the indication for its use.

At 10:15 a.m. on 5/25/11, Patient 24 was observed in the acute dialysis unit moaning during treatment. When asked if the patient was in pain or uncomfortable, a licensed staff stated that Patient 24 was "always doing that," and that she was "confused." Review of the medical record revealed the lack of indication that an assessment to determine the reason for the behavior was conducted.

During observation of wound care dressing on 2:25 p.m. on 5/25/11, Patient 24 was moaning and repeatedly stating, "It hurts... It hurts...it hurts..." during the procedure. Review of the medical record revealed that while the patient was noted as having "mild pain" at 12:00 p.m. (on 5/25/11), there was no documentation of a reassessment to determine if the patient might require pain medication prior to the dressing change. Further review of the record revealed the lack of evidence that a care plan was developed outlining interventions to effectively assess and address Patient 24's pain discomfort.

3. Patient 22 was admitted to the hospital on 5/22/11 with several diagnoses including diabetes mellitus, hypertension, and cellulitis of the right hand. General admission notes dated 5/22/11 described Patient 22 as having no neurological and mental status abnormalities, that she was independent in all activities of daily living, and that her preferred language for discussion of health needs/management was Chuukese.

Review of the medical record revealed that patient 22 had laboratory test results dated 5/23/11 which noted a low albumin level of 2.1 (normal limits 3.4 - 5.0). In light of this, there was no indication in the record that the physician or registered dietitian was informed or that a referral was made for dietary screening as outlined in the Nursing Nutrition Screen algorithm. Review of the record also revealed the lack of evidence that a care plan was developed to address the patient's low albumin level to help facilitate wound healing.

4. Patient 23 was admitted to the hospital on 5/12/11 with several diagnoses including uncontrolled diabetes and leg cellulitis. The general admission notes dated 5/12/11 described Patient 23 as having no problems with his neurological and mental status and that he was independent in all activities of daily living.

Review of Patient 23's medical record revealed laboratory tests results dated 5/12/11 which indicated a low albumin level of 2.7 (normal limits 3.4 - 5.0). While the medical record indicated that Patient 23 was seen by a dietary technician and documentation of the encounter on 5/23/11 included blood sugar level and hemoglobin and hematocrit findings, diarrhea, food consumption, and increasing fluid intake, there was no indication that the low albumin level was identified or addressed. During an interview on 5/26/11, a nursing supervisory staff stated that laboratory results outside of normal limits should have been noted by nursing staff and conveyed to the physician. Further record review revealed the lack of written evidence that the low albumin level was identified as a problem and that a care plan was developed to increase the albumin and help the healing of the wounds.

(Please cross-refer to A395.)



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5. Patient 10 was a 15-year old female who was admitted to the facility on 5/21/11 with an admitting diagnosis of term pregnancy in labor and teen pregnancy. The pre-natal record revealed an ultrasound result of marginal placenta previa. The labor and delivery record revealed that on 5/21/11 the patient gave birth to a baby girl via vaginal delivery. The patient was discharged from the facility on 5/23/11.


On 5/25/11 at 9:45 a.m., during a review of the closed record, the Vital Signs Flowsheet showed elevated blood pressure readings up to 162/91 on 5/21/11. The physician's order form showed an order for Labetalol 20 mg. intravenous push on 5/21/11 at 2157 and was later started on Labetalol 200 mg. orally every 8 hours. This hypertensive medical management was not evident in the discharge plan of care. Although the patient's plan of care addressed several complications of delivery, there was also no evidence that patient's problem of hypertension (high blood pressure) was addressed.


Also there was no evidence of a discharge plan of care related to psychosocial needs of a teen-age mother. Although an assessment for psychosocial need was conducted by the nurse and a referral to social services was done, the social worker's documentation did not focus on teen pregnancy when the patient's mother as the primary caregiver was determined as an "adequate" social support system..


On 5/26/11 at 4:20 p.m., during an interview, the social worker stated that they rely heavily on the nurses assessments and referral. However, social workers conduct psychosocial assessments on their own and participate in the formulation of discharge plan of care.


6. Review of medical records of Patient 8 and 9 who were in Neonatal Intensive Care Unit (NICU) revealed special nutritional needs as identified by nursing. The plans of care did not include any input from the dietitian. The Unit Manager from NICU and Nursery stated that nutritional needs are assessed and managed by babies' physician and rarely referred to the dietitian.

Based on observation and interview the facility failed to ensure that drugs and biological must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care and accepted standards of practice. Failure to ensure that drugs and biological are prepared and administered in accordance with accepted standards of practice, facility policies and with Federal and State laws could subject the patients to an increased risk for medication errors.

Findings include:

1. On 5/23/2011 Operating Room Suite 1 was toured with LN 2. The nurse indicated a case had finished in Suite 1 earlier that day. The anesthesia cart was observed to have 2 five ml syringes without needles on the working surface area of the cart. Syringe number 1 was labeled as propofol and it had 1ml of whitish medication in the barrel of the syringe. Propofol is a short-acting hypnotic medication used during the initiation or maintenance of general anesthesia it can also be used for sedation of those patients that are mechanically ventilated or undergoing special procedures. Syringe number 2 was labeled with the following medication labels Fentanyl (a potent synthetic narcotic analgesic), Lidocaine (local anesthetic), and Midazolam (a short-acting drug in the Valium like family). The syringe did not have the quality of each medication on the syringe however there were 3ml of fluid in the syringe. During a concurrent interview, the LN indicated that she would have expected the anesthesiologist would have discarded the medications when the case was completed.

During an interview with Dr.26 on May 25, 2011 at approximately 3PM he indicated his expectation would have been for the anesthesiologist to discard the medications in the syringes if he was finished with the operative case.




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2. During a tour of the ED (Emergency Department) on 5/25/11 at approximately 11:30 a.m., the following
was observed:

a. In the 'suture room', a 30cc multi-dose vial of Lidocaine 1% was opened (seal removed) and some of the contents removed, and there was no date on the container indicating the date it was opened.
There was also a 30cc multi-dose vial of Xylocaine with Epinephrine had been opened (seal
removed), and there was also no date on the container indicating when it was opened.

b. In the medication storage room behind the main nursing station, there was an opened multi-dose vial of Humulin 70/30 in the refrigerator that had been opened. the label on the container indicated it had been opened on 4/23, and had an expiration of 5/23/11.

During an interview with L25, she stated that the multi-dose medication vials should have had an expiration date, and the the Humulin container should have been discarded after 5/23/11.

Review of the Drug Storage Policy indicated that "Multiple dose vials must be discarded 28 days after it is opened or when the manufacture's expiration date is reached whichever is less".

Based on interview and record review the facility failed to ensure that three of 30 patient medical record entries were be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. Failure to ensure the medical records are legible and complete can contribute to adverse patient outcomes.

Findings include:

1. On 5/25/11 the closed medical record of sample patient number 25 was reviewed with Manager 3. The Manager acknowledged the record revealed that the H&P, medical orders written on 4/04/2011 were not dated and timed. Additionally the Post Anesthesia Care Routine Orders were not dated, timed and the anesthesiologist's signature only had one letter which the staff could not ascertain whose signature it was. The section of the Anesthesia Record for the Post Anesthesia Note was left completely blank by the anesthesiologist; there was no note addressing an evaluation of the patient's respiratory function/rate, mental status, temperature, pain, nausea/vomiting and hydration status; the section was signed, however it has not dated nor timed.


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2. On 5/25/11 at 9:40 a.m., during a closed record review of sample Patient 10 revealed an "In-Patient Registration Admission and Discharge" face sheet that contained information regarding patient's principal and secondary diagnoses, complications, principal and secondary procedures. The physician's handwritten entries were not legible and difficult to read. When asked for assistance to read the physician's handwritten entries, two medical records staff were unable to read them. One of the medical records staff indicated that it has always been a problem to read the handwriting of Patient 10's physician.


3. On 05/23/11 at 11:45 a.m., the unit manager in adult intensive care unit (ICU) revealed that Patient 7 has an order for physical restraints after he was intubated due to attempts of pulling out the endotracheal tube (ETT)

A review of the patient's medical record revealed he was admitted on 05/11/11 in the medical floor with diagnoses of right lower lobe lung mass associated with hemoptysis. The patient was admitted to the adult ICU on 05/16/11, intubated and connected to a mechanical ventilator.

Review of the Nurse's Notes revealed that on 05/16/11 at 10:25 a.m. - 11:25 a.m., the patient agreed to intubation for 5 days. After the intubation was completed, the patient was restless and 2 milligrams (mg) of Versed was given twice, however, the patient continued to be agitated, bucking the ventilator. Vecoronium 10 mg was given intravenously, after which the patient calmed down.

The medical record also showed that on 05/16/11, at 11:00 a.m., the physician ordered soft restraints to be applied on the patient's right and left wrists for 24 hours. The Medical-Surgical Restraint Order form indicated the following behaviors as justification for the restraint order: "pulling on lines or tubes; forgetful, impulsive, limited safety awareness; fall potential; and sedation."

On 05/26/11 at 9:00 a.m., the unit manager stated that the physical restraint ordered for Patient 7 was never applied because the patient's agitation post intubation was controlled by sedation. The unit manager also confirmed that after the physician's order was written, there was no documentation in the medical record that the physical restraint order was not carried out because sedation was effective in addressing Patient 7's behavioral problem of pulling out the ETT.

Based on observation, interview and record review, the facility did not ensure that all orders, including verbal orders were signed, timed and authenticated promptly by the ordering practitioner.

Finding includes:

1. On 5/25/11 at 9:45 a.m., during a closed record review of sample Patient # 10, the physician's verbal orders written on 5/21/11 at 8:05a.m., 5/21/11 at 8:48a.m., 5/21/11 at 9:50p.m., 5/21/11 at 10:57p.m. were not signed by the ordering physician.

In an interview, the medical records staff revealed that verbal orders should be signed by the ordering physician within 24 hours.


Review of the Medical Staff Bylaws last revised on 2/1/10 revealed that "telephone and verbal orders shall be countersigned within 24 hours by the physician who gave the order, or by the physician alternate."




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2. On 5/25/11 the closed medical record of sample patient number 25 was reviewed with Manager 3. The Manager acknowledged the record revealed that the H&P and medical orders written on 4/04/11 were not dated and timed. Additionally the Post Anesthesia Care Routine Orders were not dated, timed and the anesthesiologist's signature only had one letter which the staff could not ascertain whose signature it was. The section of the Anesthesia Record for the Post Anesthesia Note was left completely blank by the anesthesiologist; there was no note addressing an evaluation of the patient ' s respiratory function/rate, mental status, temperature, pain, nausea/vomiting and hydration status; the section was signed, however it has not dated nor timed.



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3. The physician did not sign the medical-surgical restraint order for Patient 2 on 4 occasions.

On 5/24/11 Patient #2 was transferred to the medical surgical unit of the hospital. The medical record showed that the patient had been placed in 2 soft wrist restraints on 5/19, 5/20,5/21, and 5/24/11 without a medical order. The forms had as assessment of the resident checked off but it did not indicate which staff had made the assessment.

On 5/25/11 at 11 a.m. the nurse manager for the unit was interviewed and she agreed that the orders were unsigned and stated that it was hospital policy for the physician to sign the order for soft wrist restraints every 24 hours.

Based on interview and record review the hospital failed to ensure that a medical history and physical exam was completed no more than 30 days before or 24 hours after admission, and prior to a surgery/procedure requiring anesthesia services.

Findings include:

1. Sampled patient number 15 was admitted to the hospital 4/26/11 for a total hysterectomy and other indicated surgical procedure(s). Review of the medical record indicates the patient had the procedure done using general anesthesia. Further review of the medical record revealed a History and Physical Examination form completed, but not dated until 5/22/11.

During an interview with the Medical Records staff 28 on 5/25/11 at 4:30 p.m., she indicated that the physician had recently come in to date the form, but could not verify as to when the history and physical exam had actually been completed on the patient.

Based on interview and record review the facility failed to ensure all patient medical records contained a discharge summary with outcomes of hospitalization, disposition of case, and provisions for follow-up care.

Findings:

1. On 5/25/11 the closed medical record of sample patient number 25 was reviewed with Manager 3. The Manager acknowledged the record revealed there was no discharge summary or post operative report in the medical record. On 5/26/11 the GMHA Medical Staff Bylaws dated 2/01/2010 were reviewed. On page 17 of the Bylaws under the section addressing medical records of patients undergoing operative or other invasive procedures it states that the competed operative report is authenticated by the surgeon and filed in the medical record as soon as possible following surgery. Patient 25 had surgery on 4/03/2011 and was discharged on 4/05/2011; approximately 48 days after the procedure there was still no discharge summary in the medical record.





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2. On 5/25/11 a review of the medical record for a Non Sampled patient found that the patient had been admitted in 9/1/2006 and discharged on 1/11/2007. The discharge summary was dictated by the physician on 7/28/07 and Transcribed and signed by the physician 7/30/2007. On 5/25/11 at 11a.m. Manager 3 was interviewed and she stated that the discharge summary was due within 30 days of discharge and this patients summary was not completed for 6 months. She stated that this is an ongoing challenge for her department.

Based on observation and interview the facility failed to ensure that all drugs and biologicals must be kept in a secure area, and locked when appropriate. Failure to have drugs and biologicals secure and locked when appropriate could lead access of the agents by unauthorized staff.

Findings include:

On 5/23/11 the Operating Room areas and four Operating Room Suites were toured with LN2 at approximately 10:00a.m. The LN indicated that a case had ended earlier that day and surgical cases would be started later that day after 1:00p.m. In each OR suite there was an anesthesia medication cart that was unlocked. All four anesthesia carts contained multiple medications used by anesthesia services. Some of the medications in the carts included: Lasix, Robinul, Vecuronium, Rocuronium, Succinylcholine, Atracuriu, Calcium chloride, 1 and 2% Lidocaine, Neostigmine, and antibiotics. In OR Suite 1 the anesthesia cart was observed to have 2 five syringes without needles on the working surface area of the cart. Syringe number 1 was labeled as propofol and it had 1ml of whitish medication in the barrel of the syringe. Syringe number 2 was labeled with the following medication labels Fentanyl (a potent synthetic narcotic analgesic), Lidocaine (local anesthetic), and Midazolam (a short-acting drug in the Valium like family). The syringe did not have the quality of each medication on the syringe however there were 3ml of the possible liquid mediation in the syringe. During a concurrent interview the LN indicated the anesthesiologist should have discarded the medications when the case was completed. On further investigation the LN2 stated the expectation would be for the anesthesia carts to be locked if they are not in use.

Based on observation and interview the facility failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use.

Findings include:

On 5/23/11 the Operating Room Core, four Operating Room Suites and the common work area of the OR were toured with LN2 at approximately 10:00a.m. In OR suite number one the anesthesia cart was observed to be unlocked. Within the cart were multiple medications and other items used by anesthesia providers. One 5ml vial of Flumazenil 0.5mg/5ml was observed uncapped opened, and the vial was not dated nor initialed by the person who opened the medication. During a concurrent interview with LN2, the nurse indicated that the medication should have been labeled with the date the medication was opened and the medication would be good for approximately 28 days after the open date. The initial tour of the Operating Room Core occurred with LN2 and an anesthesia technician. The OR Core is an area where extra operating room supplies were stored. There is one blanket warmer in the OR Core. Within the warmer there were blankets and liter bags of IV Normal Saline and Lactated Ringers. During a concurrent interview with the anesthesia technician she stated the IV fluids were good for 14 days after being placed in the warmer. The staff would know when the fluids expired because the bags were labeled with the expiration date 14 days from the date the fluids were placed in the blanket warmer. When examining the IV fluids the LN and anesthesia technician acknowledged there were 6 liter bags of Lactated Ringers and 2 liters bags of Normal Saline IV fluids that had no date on the outer wrapper of the bag. They agreed without dates on the outer wrapper it would be difficult to ascertain when the aforementioned IV fluids were placed inside the warmer or when the 14 day expiration period would occur. On further examination of all the IV fluids in the warmer LN2 and the anesthesia technician acknowledged there were 4 liter bags of Lactated Ringers had lapsed expiration dates; one bag had date of 5/17/11 and three bags had expiration dates of 5/22/11.

Based on interview and record review the facility staff did not take precautions to ensure that damaged radiology shields were removed from service. Failure to ensure that damaged protective devices were promptly removed from service created a potential risk for unnecessary exposure to radiation for patients.

On 5/24/11 at 10 a.m. the manager of radiology department reviewed the report of the annual inspection of the lead shield gowns. These gowns are protective devices used in the radiology department for patient safety. The report titled GMHA Radiology Lead Shield Inspection dated 2/24/09 listed gown #10 had failed the test. The same titled report dated 4/14/11 listed gown #10 had failed the test. The manager stated that the gowns and other protective devices were not uniquely identified and he could not tell if the gown #10 was the same one in both reports.

Based on record review and interview the facility failed to have a radiologist sign or record interpretations for 232 radiology services ordered. This provided opportunities for delays in medical care and inadequate medical care for the patients.

The findings include:

On 5/25/11 at 11 a.m. the director of medical records provided two lists of incomplete radiology records. The first list of 128 patients was titled "Orders Without Results " and the director stated that this represented radiologic procedures for which there were no interpretation or radiologist's signature. The second list was titled "Orders with Preliminary Results" and the director stated that this represented radiological procedures which had not had a final reading and were not signed by the radiologist.

On 5/25/11 at 11:30 a.m. the director of the radiology department was asked about the status of the 232 radiology reports. He stated that he and other staff were aware of the problem. There was a departmental plan being developed to address the issue but it had not been enacted.

On 5/27/11 at 1:15 p.m. the medical director of the hospital was interviewed regarding the outstanding radiology reports. He stated that the problem was known to the administration and that a plan had been discussed but had not been enacted.

Based on observation, interviews and record review, the facility did not ensure that technical personnel were competent in their respective duties.

Findings include:

On 5/23/11 at 3:20 p.m. during the initial tour of the kitchen with the cook who was acting as the dietary supervisor (DS), the following were observed:

1. Ice build-up on the lower corner of the walk-in chiller/freezer door.

2. Dust build-up in the electrical lines connected to the ceiling light fixture in close proximity to the exhaust fan inside the walk-in chiller/freezer.

3. Oil build-up in the kitchen floor in the areas where food frying was done to the dishwasher area causing some floor tiles to be slippery and other areas to be sticky due to droplets of dried cooking oil and grease.

4. Four (4) missing tiles in the inside wall of the housekeeping closet crating a hole in the wall approximately 4 by 6 inches in size.

5. A dumpster dedicated to dietary services located outside the kitchen was observed full and overflowing of white trash bags was left open. This observation was confirmed with DS and upon interview, he indicated that the dumpster was a temporary trash container designated for dietary use.

6. Inside the three (3)-door chiller, the following large cuts of raw meat thawing and unlabeled:

(a.) 40 pounds (lbs.) of pork loin
(b.) 10 lbs. of beef sirloin
(c.) 80 lbs. of chicken.


In an interview with the DS on the same day, he confirmed that the large cuts of meat thawing were unlabeled. He indicated that the frozen meats were pulled out from the freezer on 5/22/11 (Saturday) and will be used on 5/25/11 (Wednesday).


Review of the facility policy and procedure revealed that all raw meat, poultry pulled out from frozen storage must be labeled with the name of food item and quantity, intended purpose should be indicated, date of pull-out and date of discard-by.


8. An unlabeled plastic container that the DS identified as sugar was observed stored in a kitchen counter next to a stack of 5-lb bags of flour.


9. An unlabeled bin that contained few grains of rice and two other unlabeled empty bins for dry food storage were observed in the kitchen area. The DS stated that they were in the process of emptying the bins to clean the inside part of the container but confirmed that the rice bin was not labeled.


10. Inside the walk-in chiller, there were three sheet pans of cooked chili stored on the second and third shelves of four-tiered food cart. On the first and top shelf was an open box of frozen crab meat. The DS stated that the crab meat was being thawed for Wednesday (5/25/11) use.


11. Also, the top shelf had an open box of siobao (pork bun). The DS stated that the food belonged to dietary staff and he was uncertain of the source of the food item whether store bought or prepared at home.


On 5/26/11, a review of the staff meeting binder provided by the dietary staff revealed that the last training conducted specific to dietary issues was year 2009 and this was confirmed by the Food Service Administrator (FSA). She also revealed that for the last couple of years the training was centered on hospital-wide issues such as patient safety.

Based on record review and interview, the hospital did not ensure that the nutritional needs of each patient were evaluated and met in accordance with recognized dietary practices.

Findings include:

1. Patient 23 was admitted to the hospital on 5/12/11 with several diagnoses including uncontrolled diabetes and leg cellulitis. General admission notes dated 5/12/11 described Patient 23 as having no problems with his neurological and mental status and that he was independent in all activities of daily living. Review of the medical record revealed that Patient 23 had a physician's order dated 5/12/11 for an 1800-calorie, low salt, low fat diet.

Further record review revealed that Patient 23 had laboratory tests results obtained on 5/12/11 which noted a low albumin level of 2.7 (normal limits 3.4 - 5.0). While the medical record indicated that Patient 23 was seen by a dietary technician and documentation of the encounter on 5/23/11 included blood sugar level and hemoglobin and hematocrit findings, diarrhea, food consumption, and increasing fluid intake, there was no indication that the low albumin level was identified or addressed. In addition, while the same notes indicated that the dietary technician "will continue to follow-up per protocol," no further follow-ups such as referral to the registered dietitian or physician were made.

2. Patient 22 was admitted to the hospital on 5/22/11 with several diagnoses including diabetes mellitus, hypertension, and cellulitis of the right hand. General admission notes dated 5/22/11 described Patient 22 as having no neurological and mental status deficits, that she was independent in all activities of daily living, and that her preferred language for discussion of health needs/management was Chuukese. Review of the medical record also revealed that Patient 22 had a physician's order dated 5/23/11 for an 1800 calorie diet.

Further review of the record revealed laboratory test results dated 5/23/11 which noted that Patient 22 had a low albumin level of 2.1 (normal limits 3.4 - 5.0). This notwithstanding, there was no indication in the record that the physician and/or registered dietitian were informed, or that a referral was made for an assessment of the patient by the registered dietitian as outlined in the Nursing Nutrition Screen algorithm. Review of the record also revealed the lack of evidence that a care plan was developed outlining measures to address the low albumin level.

During an interview on 5/26/11, a registered dietitian (Staff 3) explained that screening for nutrition-related risk factors was part of the Nursing General Admission Assessment conducted within 24 hours of admission. Review of the Nursing Nutrition Screen algorithm provided by Staff 3 indicated that a response of "yes" to any three questions about special diets, nutrition related diagnosis, and nutrition related condition would prompt a screening by the dietary technician. The algorithm also noted that the dietary technician would categorize the risk (i.e. low, medium, or high risk) and that based on the risk level, a re-screening or a "comprehensive Nutrition Assessment within 24 hours" will be conducted by the registered dietitian.


Further review of Patient 22 and 23's medical records however revealed the lack of documented evidence that a dietary screening identifying the low albumin level and classification of the nutritional risk were conducted. In addition, there was no evidence that follow-ups were made to ensure that the registered dietitian and physician were aware so that appropriate interventions could be developed and implemented promptly.

Based on observation, interviews and record review, the facility did not ensure that a current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing and food service personnel.

Finding includes:

On 5/26/11, the dietary staff presented a binder labeled Hawaii Diet Manual as the therapeutic manual currently used by the dietary staff. The certification page of the manual showed that the dietary manual was reviewed however the signature page of the manual indicated that the manual was reviewed on year 2002 and approved by the Board of Trustees on 10/23/02 (nine years ago).

The publication or revision date of the approved therapeutic diet manual must not be more than five years old.

On 5/26/11 at 4:30 p.m., interview with the Food Service Administrator (FSA) confirmed that the therapeutic manual used by the facility was the Hawaii Diet Manual that was an old publication and needed revision.

Based on observation, interview and record review, the hospital was not constructed, arranged, and maintained to ensure the safety of its patients as evidenced by its failure to ensure that the physical plant and overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients are assured (A0701), and failure to comply with the requirements of the National Fire Protection Agency, 2000 Edition, Life Safety Code Standard (A0709). The cumulative effect of plant maintenance and the non-compliance with Life and Safety Code resulted in the failure of the hospital to provide care and services in accordance with regulatory requirements under Physical Environment.

Based on observation and interview, the hospital was not maintained to ensure the safety of its patients as evidenced by its failure to ensure that the physical plant and overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured.

Findings inculude:
Discolored/ moldy ceiling tiles were noted at the following locations:

On 5/23/2011:
3:30pm- Room A113 Physical Therapy: 9 ea
4:00pm- Medical Records: 1 each
4:30pm- Stairwell #4: 2 each

On 5/24/2011
8:20 am- Registration/ Medical Records near exit signs- 5 each
8:20 am-Under chilled water line due to bad insulation- 2 each
8:20 am- Break room- 4 each
9:00 am- Laboratory Corridor D242: 5 each
9:40am- Lab room D230: 9 each
9:40am- Lab room D226: 4 each
9:40 am- conference room D234: 1 each
10:10am- room A246: 3 each
10:10am-ER waiting room: 7 each
11:00 am- ER annex room E211: 4 each

Moldy sheetrock on ceiling:
On 5/24/2011
11:00am- Stairwell #2, 4th floor: 1ft x 2 ft

The facility biomedical engineer stated that insulation was breaking down on a chilled water line causing water damage.
The facility biomedical engineer acknowledged the findings at the time of observation.
Moldy surfaces may cause allergic reactions in susceptiable individuals.

Based on observation, interview, and document review, the hospital failed to be in compliance with the requirements of the National Fire Protection Agency, 2000 Edition, Life Safety Code Standard.

Findings include:

Cross-refer to the findings during the Life Safety Code survey dated 5/27/2011.

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Based on observation and interviews, the facility did not ensure that facilities, supplies and equipment be maintained to ensure an acceptable level of safety and quality.

Findings include:

1. On 5/23/11, at 10 a.m., in Labor and Delivery Room #1, the floor area below the delivery table was yellow- stained with Betadine.

2. In Obstetrics (OB) unit, a gerichair with torn vinyl cushion approximately 4-5 inches in length was observed in patient room # 218.

3. On 5/23/11 at 11:45 a.m., during the initial tour, in the center of the adult Intensive Care Unit (ICU) was water stained ceiling (one-two ceiling tiles). Eight of the 10 rooms had windows to the outside with missing blind slats.

4. On 5/25/11 at 4:00 p.m., in Telemetry Unit, the medication refrigerator for narcotics only had a large accumulation of ice in the freezer. Per unit manager, she needed to do a work order for Facility Maintenance (FM).

5. On 5/23/11 at 10:45 a.m., during the initial tour in Neonatal Intensive Care Unit (NICU), portable air-conditioning (A/C) units were observed in the NICU and in Nursery areas. Interview with the Unit Manager revealed that there was an electrical outage over the weekend. The portable A/C units were provided by FM who was still working on providing a comfortable temperature for the babies. On 5/24/11 at 3:30 p.m., the portable A/C unit was observed in NICU. The room temperature measured at 76 - 78 degrees Fahrenheit. Per unit manager the recommended room temperature should be 70 - 72 degrees Fahrenheit.

6. On 5/26/11 at 1:00 p.m., the Medication Refrigerator #1 in Pharmacy was observed with black spotted particles in the inside wall of the refrigerator unit. Upon wiping the inside wall of the refrigerator with a disposable paper towel, it was determined that the black particles were an accumulation of dust and dirt from the refrigerator air vent.

7. During the initial tour on 5/23/11 and throughout the survey, the wall switch controlling the lighting fixture above the hand washing sink inside the nursing station in the PCU-Telemetry unit was observed cracked on the right. In addition, the switch which was also adjacent to the sink was stuck and inoperable.

During an interview, a licensed staff on the initial tour on 5/23/11 stated that she did not know how long the switch had been broken.

Based on observation, interview and record review, the hospital did not ensure that person or persons designated as infection control officer or officers implemented policies and procedures governing control of infections and communicable diseases.

Findings include:
1. During observation of medication pass on 5/25/11 at 9:35 a.m., medications intended for Patient 34 (an unsampled patient) including both oral and injectable were brought to the patient's room for administration by the licensed medication nurse. With the medications, the licensed staff also brought the MAR (medication administration record) which she removed from the Kardex kept on top of the medication cart located in the nursing station. Once in the room, the medication nurse placed all of the medications and the MAR directly on the patient's overbed table without sanitizing the surface to ensure that there was separation between clean and dirty areas and that the MAR was protected from potential contamination. The overbed table was observed to contain several patient care items including a water pitcher, bananas, a small tissue box, and a covered plate containing food items.

After the medications were administered, the licensed nurse replaced the MAR in its slot within the Kardex. When asked how the MAR was protected from contamination when brought inside a patient's room, the licensed staff had no explanation but stated that the MAR was used as a reference during the pass.

Review of Patient 34 revealed that he was admitted for leg infection and sepsis and was receiving several medications including antituberculoidals.

2. Patient 23 was admitted to the hospital on 5/12/11 with several diagnoses including uncontrolled diabetes and leg cellulitis. Review of the medical record revealed that the patient had a physician's order dated 5/12/11 for wet to dry dressings on the wounds on his right leg daily.

During observation of wound dressing change at 11:00 a.m. on 5/25/11, the licensed staff began the procedure by donning two gloves on each hand. The licensed staff thereafter opened a drawer on the patient's nightstand and obtained supplies including several pieces of dressings, Kerlix bandage, and adhesive tape which were assembled on the overbed table at the patient's bedside. The staff also obtained the treatment record (where the treatment order was transcribed), an unopened plastic container of saline solution, and from the drawer (of the nightstand) retrieved a used and opened suture set kit which contained a disposable pair of scissors and thumb forceps. All these items were placed on the same overbed table. The staff then opened the sterile dressings and cut the tape with the scissors to the desired length.

The licensed staff prepared the patient by repositioning him and elevating his right leg and placing a disposable protective pad under it. The staff then started cutting the old Kerlix dressings using scissors from the opened suture kit. Observation of the old dressings on the wounds revealed moist yellow drainage.

After the right leg was exposed, the staff began removing the old wet-to dry dressings from each wound using the forceps from the opened suture kit. To facilitate removal, the staff, without changing gloves, reached for the new saline container on the overbed table, broke the seal, removed the lid, and poured the solution over the old dressings. The staff then continued pulling on the dressings with the forceps until all were removed.

After gathering the old dressings, wrapping them with the protective pad, and disposing them off in a plastic receptacle, the staff removed the first layer of gloves and carried on.

Using the same saline container which was held with one hand, the staff then poured solution over the wounds cleaning each with the other hand using new dressings. When all the wounds were cleaned, the staff, without changing gloves or hand washing, proceeded to moisten several pieces of dressings which were then applied on each wound. The staff thereafter, without changing gloves or hand washing, covered each wound with 4 x 4s and held them in place with a roll of Kerlix.

Using the same gloves, the staff proceeded to clean up and disposed dressing wrappers in the trash receptacle. Unused supplies were returned to the drawer including the container of saline solution which was placed on the nightstand. Without cleaning the used scissor and forceps, these too were returned in the packet and placed inside the drawer. The staff thereafter removed the used gloves, washed her hands inside the patient's bathroom, took the treatment record from the overbed table, left the patient's room and replaced the record in its slot in the Kardex.

During the observation, the staff did not distinguish between dirty and clean procedures and did not wash hands or changed gloves in between. In addition, reused instruments and supplies that were potentially contaminated after direct contact with old dressings were neither disposed off nor cleaned or disinfected.

Review of the hospital's policy on the application of wet-to dry dressings (revised 12/09) required the washing of hands and the application of a plastic apron and clean gloves. In the addition, the policy required staff to "Wash hands. Establish a sterile field with all of the equipment and supplies you will need for wound care ..." The policy further noted to "Dispose of all soiled equipment and supplies appropriately."

3. Patient 24 was admitted to the hospital on 5/20/11 with several diagnoses including end-stage renal disease with dialysis, debridement of a sacral pressure sore, and anemia. The medical record revealed that Patient 24 had two Stage 4 pressure ulcers one of which was located in the sacral area and the other on the left hip. Further review of the record revealed that Patient 24 had a physician's order for wound care dated 5/22/11 for Betadine (an antiseptic) sugar packs to the left hip decubitus ulcer twice daily; and on 5/23/11, another physician's order was made for the use of wet-to-dry dressings on the sacral pressure ulcer.

At 2:25 p.m. on 5/25/11, observation of wound care for Patient 24 involving another licensed staff member was conducted. The staff began the procedure by placing all of the needed supplies and solution on the overbed table which was next to the patient's bed. The treatment record which was obtained from the Kardex was also placed on the table. Using a new pair of gloves, the staff repositioned the patient on her right side to expose the sacral area and the left hip ulcers. The staff thereafter began by removing the old dressing from the sacral area and putting this on a blue protective pad that was on the bed. To facilitate removal of the old dressing, the staff poured saline solution from a plastic container which she held with the other hand. The dressing was noted to have a large amount of serosanguinous drainage. Once the dressing was removed, the staff disposed this off in a trash receptacle together with the gloves.

Putting on new gloves, the staff who was wearing a long sleeve shirt started cleaning the pressure ulcer with gauze and saline solution. On several occasions, the sleeves of her shirt were observed going down her arms and each time, she pulled them up with her gloved hands. After cleaning the ulcer, the staff, without washing her hands or changing gloves, moistened several lengths of new gauze dressing with saline solution and applied them on the ulcer. The staff thereafter covered the newly dressed ulcer with an ABD pad and held it in place with an adhesive tape. Using the the same gloves used to clean the wound and apply the new dressing, the staff reached for a pen attached to her identification card and uniform top and noted the time and date of the dressing change on the ABD pad. Thereafter, the staff collected the used gauze that were in the blue pad, and folded and discarded them in the trash container.

The same staff began the dressing change on the left hip pressure ulcer donning new gloves and moving to the other side of the bed. A large amount of serosanguinous drainage was noted on the old dressing. To facilitate removal, the staff poured saline solution over the old dressing from the same container used earlier. After the left hip dressing was removed, it was placed on a blue pad that was on the bed next to the patient. Thereafter, the staff folded the blue pad and discarded it and its content in the trash container. At this time, the staff removed her gloves and washed her hands in the patient's bathroom.

The staff then put on a new pair of gloves and began cleaning the ulcer with gauze and saline solution. During the procedure, the staff was also observed pulling up her sleeves every time they rolled down with her gloved hands. After the ulcer was cleaned, the staff, without washing her hands or changing gloves obtained a piece of new dry dressing, moistened it with saline and applied it on the ulcer. The ulcer was then covered with additional dry dressings that were securely taped in place. With the same gloves, the staff then used the pen attached to her identification card and noted the date and time of the dressing change on the new dressing.

At this point, the staff paused and stated that she "just remembered" that Patient 24 had a new treatment order consisting of Betadine sugar paste. Using the same gloves, the staff then went to check the treatment record that was on the overbed table at the other side of the bed. After verifying the order, the staff, still using the same gloves, removed the new dressing on the left hip; and with the same gloves re-did the dressing applying the Betadine sugar paste and then covering it with 4 x 4s. The staff thereafter noted the date and time of the procedure on the new dressing with the same pen and gloves.

After the dressing change, the staff removed the gloves and placed them on the blue pad that was still on the bed. Using her bare hands, the staff then rolled the blue pad and discarded it in the trash receptacle. Without washing her hands, the staff left the room holding the treatment record which was then replaced in the Kardex.

During the procedure, delineation of clean and dirty procedures as well as the changing of gloves and hand washing between clean and dirty procedures were not observed.

During an interview on 5/26/11, the infection control nurse stated that the hospital had conducted several in-services on infection control which included observance of hand washing and changing gloves during each patient contact.

4. During the initial tour on 5/23/11 at about 11:15 a.m., two plastic bags were observed inside the refrigerator in the medical surgical unit. The staff on the tour stated that the refrigerator was used to store food items and other supplies such as juices intended for the use of patients on the unit. The staff added that patient food items should not be kept in the refrigerator because of the concern for contamination. The added further stated that hospital policy did not allow patients to bring in food to the hospital from the outside.

Based on record review and interview, the hospital did not ensure that a registered nurse, social worker, and other appropriately qualified personnel developed the discharge evaluation.

Findings include:

1. Patient 24 was admitted to the hospital on 5/20/11 with several diagnoses including end-stage renal disease with dialysis, debridement of a sacral pressure sore, and anemia. Nurses notes dated 5/20/11 described Patient 24 as alert, oriented to person, but "unable to verbalize thoroughly." General admission notes dated 5/20/11 further described the patient as dependent on staff for all activities of daily living (ADLs) including eating and bed mobility.

Review of the medical record revealed that Patient 24 lived with family members including her husband and a sister at home. The record also noted that the patient had acquired pressure ulcers at home on her sacral area and left hip. Admission nurses notes dated 5/20/11 described the pressure sores as being a "Stage 3." On 5/27/11, the wound assessment noted that Patient 24's pressure ulcers were described as Stage 4 and that the left hip ulcer measured 5.6 cms X 6 cms X 2 cms; and the sacral ulcer, 9.5 cms X 8 cms X 3 cms in size.

The initial discharge assessment dated 5/20/11 described Patient 24 as confused and disoriented. The assessment also noted the need for home health care services for wound care, and referrals to medical social and rehabilitative services. Problems identified following the assessment included impaired integrity, pressure sores, and anemia.

Review of the medical record revealed that while the initial assessment was conducted, there was no documentation of any follow-up to ensure that the problems outlined were addressed. While the problem for "impaired skin integrity," for example, noted that "if wound care will be necessary after hospital discharge, teach dressing change procedure to patient and significant other," there was no documentation if this was carried out or if the responsible caregiver for this undertaking had been identified.

Further review of the medical record revealed the lack of documentation of social services participation in the discharge planning. During an interview on 5/26/11, a social service staff (Staff 17) stated that Patient 24 did not trigger social services in spite of the referral because she had a family consisting of her husband and sister and that she had a home. When asked if the pressure ulcers acquired at home might have triggered a referral, Staff 17 stated that abuse assessment which was part of the general admission assessment did not indicate so.

Review of the hospital's social services consultation and referral procedures (endorsed FP 07/2009) revealed that while it outlined the different social services provided, the policy however did not specify conditions necessitating a social service referral. The hospital's policy and procedure on initial admission/discharge planning/reassessment process (revised 08/2009) also did not specify social services role in the discharge planning. While the policy noted that "nursing will make applicable referrals, upon physician's orders, to the other interdisciplinary care team members," the policy did not establish criteria for social services referral so that roles and expectations were clear and defined.

Review of the medical record on 5/27/11 revealed a physician's order (dated 5/27/11) that Patient 24 could be discharged home after dialysis. Further record review revealed that after the initial discharge assessment conducted on 5/20/11, there was a lack of written indication of interdisciplinary team participation in Patient 24's discharge planning. In addition, there was no documentation of the implementation of interventions addressing the problems identified during the initial discharge assessment to assist Patient 24 transition from hospital inpatient care to home care.



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2. Patient 10 was a 15-year old female who was admitted to the facility on 5/21/11 with an admitting diagnosis of term pregnancy in labor and teen pregnancy. The pre-natal record revealed an ultrasound result of marginal placenta previa. The labor and delivery record revealed that on 5/21/11 the patient gave birth to a baby girl via vaginal delivery. The patient was discharged from the facility on 5/23/11.


On 5/25/11 at 9:45 a.m., during a review of the closed record, the Vital Signs Flowsheet showed elevated blood pressure readings up to 162/91 on 5/21/11. The physician's order form showed an order for Labetalol 20 mg. intravenous push on 5/21/11 at 2157 and was later started on Labetalol 200 mg. orally every 8 hours. This hypertensive medical management was not evident in the discharge plan of care. Although the patient's plan of care addressed several complications of delivery, there was also no evidence that patient's problem of hypertension (high blood pressure) was addressed.


Also there was no evidence of a discharge plan of care related to psycho-social needs of a teen-age mother. Although an assessment for psycho-social need was conducted by the nurse and a referral to social services was done, the social worker's documentation did not focus on teen pregnancy when the patient's mother as the primary caregiver was determined as an "adequate" social support system..


Interview with the staff developer on 5/26/11 at 4 p.m., she indicated that registered nurses are not thoroughly trained with identifying the psychosocial needs of patients.


On 5/26/11 at 4:20 p.m., during an interview, the social worker stated that they rely heavily on the nurses assessments and referral. However, social workers conduct psychosocial assessments on their own and participate in the formulation of discharge plan of care.

3. Review of medical records of Patient 8 and 9 who were in Neonatal Intensive Care Unit (NICU) revealed special nutritional needs as identified by nursing. The plans of care did not include any input from the dietitian. The Unit Manager from NICU and Nursery stated that nutritional needs are assessed and managed by babies' physician and rarely referred to the dietitian. She also indicated that there used to be a neonatologist who addressed the nutritional needs of the babies.

On 5/26/11 at 4:30 p.m., an interview with the Food Service Administrator revealed that she is not trained on the dietetic needs of neonatal patients.






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4. Sample patient number 29 is an 80 year old female who lives with her husband and was admitted into the facility on May 22, 2011. Some of her diagnoses included: Respiratory Failure and Cachexia. The medical record was review with LN3 on May 26, 2011 at 09:15AM; four days after admission. The LN3 acknowledged the patient the medical record did not contain a written discharge nursing care plan. Additional record review revealed the initial nursing assessment identified there was no indication to referral to any other department to address the patient ' s real or potential discharge home care needs (such as equipment, home health agency referral or skilled nursing facility placement). The medical record did not reflect written documentation or a nursing care plan alluding to a tentative referral to the Social Services Department, post discharge home needs or consideration of Home Health Agency/Skilled Nursing Facility placement.

Based on record review and interview, the hospital did not ensure that the discharge plan requirements are met.

Finding includes:

Patient 24 was admitted to the hospital on 5/20/11 with several diagnoses including end-stage renal disease with dialysis, debridement of a sacral pressure sore, and anemia. The initial discharge assessment dated 5/20/11 described Patient 24 as confused and disoriented. The assessment also noted the need for home health care services for wound care, as well as referrals to medical social services and rehabilitative services.

On 5/27/11, a physician's order was made that Patient 24 could be discharged home after dialysis. Further record review revealed that after the initial discharge assessment conducted on 5/20/11 which identified several problems including impaired skin integrity, pressure ulcers, and anemia, there was no documentation of any implementation of interventions developed to address these problems relative to home care. One problem, for example, under impaired skin integrity, noted that "if wound care will be necessary after hospital discharge, teach dressing change procedure to patient and significant other." Review of the record revealed the lack of documentation that this was discussed with the family or if the caregiver responsible for providing this treatment had been identified.

Based on observation, interviews, and record review, the facility did not reassess the patient's discharge plan of care if there are factors that may affect continuing care needs or appropriateness of the discharge plan.

Finding includes:

Patient 10 was a 15-year old female who was admitted to the facility on 5/21/11 with an admitting diagnosis of term pregnancy in labor and teen pregnancy. The pre-natal record revealed an ultrasound result of marginal placenta previa. The labor and delivery record revealed that on 5/21/11 the patient gave birth to a baby girl via vaginal delivery. The patient was discharged from the facility on 5/23/11.


On 5/25/11 at 9:45 a.m., during a review of the closed record, the Vital Signs Flowsheet showed elevated blood pressure readings up to 162/91 on 5/21/11. The physician's order form showed an order for Labetalol 20 mg. intravenous push on 5/21/11 at 2157 and was later started on Labetalol 200 mg. orally every 8 hours.


Review of the Post partum Discharge Instruction form #0565 dated 5/23/11 showed no special instructions on medications. There was no evidence in the discharge instructions if there were changes in the dose, frequency and duration of the antihypertensive medication.


Also there was no evidence of a discharge plan of care related to psychosocial needs of a teen-age mother. Although an assessment for psychosocial need was conducted by the nurse and a referral to social services was done, the social worker's documentation did not focus on teen pregnancy when the patient's mother as the primary caregiver was determined as an "adequate" social support system.


On 5/26/11 at 4:20 p.m., during an interview, the social worker stated that they rely heavily on the nurses assessments and referral. However, social workers conduct psychosocial assessments on their own and participate in the formulation of discharge plan of care.

Based on record review and interview, the hospital did not ensure that a registered nurse, social worker, and other appropriately qualified personnel developed the discharge evaluation.

Findings include:

1. Patient 24 was admitted to the hospital on 5/20/11 with several diagnoses including end-stage renal disease with dialysis, debridement of a sacral pressure sore, and anemia. Nurses notes dated 5/20/11 described Patient 24 as alert, oriented to person, but "unable to verbalize thoroughly." General admission notes dated 5/20/11 further described the patient as dependent on staff for all activities of daily living (ADLs) including eating and bed mobility.

Review of the medical record revealed that Patient 24 lived with family members including her husband and a sister at home. The record also noted that the patient had acquired pressure ulcers at home on her sacral area and left hip. Admission nurses notes dated 5/20/11 described the pressure sores as being a "Stage 3." On 5/27/11, the wound assessment noted that Patient 24's pressure ulcers were described as Stage 4 and that the left hip ulcer measured 5.6 cms X 6 cms X 2 cms; and the sacral ulcer, 9.5 cms X 8 cms X 3 cms in size.

The initial discharge assessment dated 5/20/11 described Patient 24 as confused and disoriented. The assessment also noted the need for home health care services for wound care, and referrals to medical social and rehabilitative services. Problems identified following the assessment included impaired integrity, pressure sores, and anemia.

Review of the medical record revealed that while the initial assessment was conducted, there was no documentation of any follow-up to ensure that the problems outlined were addressed. While the problem for "impaired skin integrity," for example, noted that "if wound care will be necessary after hospital discharge, teach dressing change procedure to patient and significant other," there was no documentation if this was carried out or if the responsible caregiver for this undertaking had been identified.

Further review of the medical record revealed the lack of documentation of social services participation in the discharge planning. During an interview on 5/26/11, a social service staff (Staff 17) stated that Patient 24 did not trigger social services in spite of the referral because she had a family consisting of her husband and sister and that she had a home. When asked if the pressure ulcers acquired at home might have triggered a referral, Staff 17 stated that abuse assessment which was part of the general admission assessment did not indicate so.

Review of the hospital's social services consultation and referral procedures (endorsed FP 07/2009) revealed that while it outlined the different social services provided, the policy however did not specify conditions necessitating a social service referral. The hospital's policy and procedure on initial admission/discharge planning/reassessment process (revised 08/2009) also did not specify social services role in the discharge planning. While the policy noted that "nursing will make applicable referrals, upon physician's orders, to the other interdisciplinary care team members," the policy did not establish criteria for social services referral so that roles and expectations were clear and defined.

Review of the medical record on 5/27/11 revealed a physician's order (dated 5/27/11) that Patient 24 could be discharged home after dialysis. Further record review revealed that after the initial discharge assessment conducted on 5/20/11, there was a lack of written indication of interdisciplinary team participation in Patient 24's discharge planning. In addition, there was no documentation of the implementation of interventions addressing the problems identified during the initial discharge assessment to assist Patient 24 transition from hospital inpatient care to home care.



14147


2. Patient 10 was a 15-year old female who was admitted to the facility on 5/21/11 with an admitting diagnosis of term pregnancy in labor and teen pregnancy. The pre-natal record revealed an ultrasound result of marginal placenta previa. The labor and delivery record revealed that on 5/21/11 the patient gave birth to a baby girl via vaginal delivery. The patient was discharged from the facility on 5/23/11.


On 5/25/11 at 9:45 a.m., during a review of the closed record, the Vital Signs Flowsheet showed elevated blood pressure readings up to 162/91 on 5/21/11. The physician's order form showed an order for Labetalol 20 mg. intravenous push on 5/21/11 at 2157 and was later started on Labetalol 200 mg. orally every 8 hours. This hypertensive medical management was not evident in the discharge plan of care. Although the patient's plan of care addressed several complications of delivery, there was also no evidence that patient's problem of hypertension (high blood pressure) was addressed.


Also there was no evidence of a discharge plan of care related to psycho-social needs of a teen-age mother. Although an assessment for psycho-social need was conducted by the nurse and a referral to social services was done, the social worker's documentation did not focus on teen pregnancy when the patient's mother as the primary caregiver was determined as an "adequate" social support system..


Interview with the staff developer on 5/26/11 at 4 p.m., she indicated that registered nurses are not thoroughly trained with identifying the psychosocial needs of patients.


On 5/26/11 at 4:20 p.m., during an interview, the social worker stated that they rely heavily on the nurses assessments and referral. However, social workers conduct psychosocial assessments on their own and participate in the formulation of discharge plan of care.

3. Review of medical records of Patient 8 and 9 who were in Neonatal Intensive Care Unit (NICU) revealed special nutritional needs as identified by nursing. The plans of care did not include any input from the dietitian. The Unit Manager from NICU and Nursery stated that nutritional needs are assessed and managed by babies' physician and rarely referred to the dietitian. She also indicated that there used to be a neonatologist who addressed the nutritional needs of the babies.

On 5/26/11 at 4:30 p.m., an interview with the Food Service Administrator revealed that she is not trained on the dietetic needs of neonatal patients.






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4. Sample patient number 29 is an 80 year old female who lives with her husband and was admitted into the facility on May 22, 2011. Some of her diagnoses included: Respiratory Failure and Cachexia. The medical record was review with LN3 on May 26, 2011 at 09:15AM; four days after admission. The LN3 acknowledged the patient the medical record did not contain a written discharge nursing care plan. Additional record review revealed the initial nursing assessment identified there was no indication to referral to any other department to address the patient ' s real or potential discharge home care needs (such as equipment, home health agency referral or skilled nursing facility placement). The medical record did not reflect written documentation or a nursing care plan alluding to a tentative referral to the Social Services Department, post discharge home needs or consideration of Home Health Agency/Skilled Nursing Facility placement.